Every 90 days, three patients from Montana fly to California to get a prescription for opioids.

“I just want humanitarian care, and I get that in California.” Gary Snook, Montana resident

As the U.S. faces an epidemic of overdose deaths from prescription painkillers, some patients with chronic pain say doctors are less likely to prescribe them opioids. Some Montana patients say the only way they can get the treatment they need is to fly out of state.

On a mid-afternoon flight out of Missoula, Montana, Gary Snook pauses in the aisle in front of seat 17B. He stretches with a slight wince and sits down.

“My pain, it is all from my waist down. It’s like being boiled in oil 24-hours a day,” Snook said.

He has been in severe pain since he had surgery on his spine for a ruptured disk 14 years ago.

Kathy Snook, Terri Anderson and Gary Snook waiting in Dr. Forest Tennant’s office in West Covina, California. Gary Snook travels from Montana to California every three months for a pain medication prescription.

The Centers for Disease Control and Prevention recently released guidelines to curb the overprescribing of opioids for chronic pain, and the Drug Enforcement Administration increased oversight and sanctions for doctors who overprescribe the drugs.

Some Montana doctors say these federal actions are scaring them away from taking on new pain patients.

“A lot of the chronic pain doctors are dropping out of the business, says Charles Farmer with the state’s medical board. “One of the reasons is because they don’t want the DEA following them around.”

The Montana medical board suspended the license of physician Mark Ibsen this year for overprescribing.

“We as physicians are terrified that we are going to go to prison or lose our license over prescribing pain pills to patients,” Ibsen said.

He denies he was overprescribing and is appealing the suspension of his license. But he shut down his practice in Helena anyway.

Pain management has always been hard, Ibsen says, and all the oversight is interfering with the doctor-patient relationship.

“The thing is there is no objective measurement of pain. If you don’t take people at their word that they are in pain, and you are suspicious of them, you can’t have a therapeutic relationship,” Ibsen says. “No miracles happen between you and me — as a patient and a doctor — if I suspect that you’re a scumbag.”

The Montana Board of Medical Examiners Executive Director Ian Marquand says he couldn’t say whether the board’s disciplinary actions have had an impact on patients’ access to opioids.

“The door is open in Montana for any qualified, competent physician to come in and practice,” Marquand said.

For some Montana pain patients, like Gary Snook, relief is only found at a strip mall clinic in suburban Los Angeles.

His doctor is Forest Tennant, a former army physician who opened his first pain clinic in 1975. Today, He has about 150 patients –- half of them are Californians and half are from out-of-state.

“The last week or two has just been unbearable,” Tennant says. “We hardly want to (answer) the phones, the number of people calling that want to come here.”

Dr. Forest Tennant treats pain patients from all over the country at his practice in West Covina, California.

He says California has laws that Montana and other states don’t, including the Pain Patient’s Bill of Rights. It allows a patient to request or reject the use of any technique in order to relieve their pain.

Tennant says that’s coupled with intensive physician training in all the other ways to treat pain before turning to opioids.

“They are the last resort, when there is no other option. You don’t use them until everything else has failed,” Tennant said.

He says opioids shouldn’t be stigmatized, they should be used responsibly.

Tennant is now helping pain patients in Montana lobby lawmakers to guarantee more access to opioids in their home state, so people like Gary Snook don’t need to travel so far for a prescription.

“I mean, it’s life and death in that bottle. At least it’s my life,” Snook said.

He says he just wants to visit a doctor near his home and be seen as patient, not a criminal.

]]>https://ww2.kqed.org/stateofhealth/2016/06/13/montanas-pain-refugees-find-relief-in-california/feed/1Waiting_RoomKathy Snook, Terri Anderson and Gary Snook waiting in Dr. Forest Tennant’s office in West Covina, Calif. Gary Snook travels from Montana to California every three months for a pain medication prescription.Tennant_OfficeDr. Forest Tennant treats pain patients from all over the country at his practice in West Covina, CA.Powerful Narcotic Painkiller Up For FDA Approvalhttps://ww2.kqed.org/stateofhealth/2014/04/22/powerful-narcotic-painkiller-up-for-fda-approval/
https://ww2.kqed.org/stateofhealth/2014/04/22/powerful-narcotic-painkiller-up-for-fda-approval/#respondTue, 22 Apr 2014 18:25:58 +0000http://blogs.kqed.org/stateofhealth/?p=18804(Getty Images)

The Food and Drug Administration is trying to decide whether to approve a powerful new prescription painkiller that’s designed to relieve severe pain quickly, and with fewer side effects than other opioids.

While some pain experts say the medicine could provide a valuable alternative for some patients in intense pain, the drug (called Moxduo) is also prompting concern that it could exacerbate the epidemic of abuse of prescription painkillers and overdoses.

An FDA advisory committee is holding a daylong hearing Tuesday to decide whether to recommend that the agency approve the drug.

“This is a product that is very easy to misuse, very easy to crush and snort or crush and inject,” says addiction specialist Andrew Kolodny.

Moxduo for the first time combines morphine and oxycodone in one capsule. It’s designed to provide quick relief to patients suffering severe pain from accidents or surgeries, such as knee replacements, back surgeries or cancer operations, says Ed Rudnic, COO of QRxPharma, the company that makes Moxduo.

The drug allows patients to take lower doses of the two narcotics than they’d need if they took either of the medicines alone, Rudnic says.

“We believe that we’ve achieved some benefit in reducing the risk of some of the respiratory complications of these strong opioids,” he says.

Suppressed breathing and other respiratory complications are the most serious risks of these drugs — the main reason people die from taking too much.

Some pain experts think the idea behind Moxduo is a good one. A lot of patients can’t take enough morphine or oxycodone to ease their discomfort because of the risk to breathing and other side effects, such as nausea, vomiting, dizziness and severe itchiness.

Patients who could theoretically benefit from such a pill are “normal people like you and me,” says Dr. Joseph Audette of Harvard Medical School. “And then suddenly we get in a terrible accident or have surgery and … we need something. And the typical agents are used, and suddenly all these terrible side effects come up.”

But Audette is not convinced the company has yet proved that Moxduo has fewer side effects.

“They haven’t really done the hard work of absolutely showing … in humans with real pain problems that synergy is making a big difference,” Audette says, “compared to just using the agents that we [already] have available.”

And some experts worry that Moxduo will come with its own problems.

“I have serious concerns about this product,” says Andrew Kolodny, an addiction specialist at Phoenix House. He also leads the Physicians for Responsible Opioid Prescribing, which is fighting for tighter control of prescription painkillers.

Millions of people are addicted to these legal narcotics already, Kolodny says, with thousands dying from overdoses each year. Moxduo, he worries, would only make that worse.

“This is pure morphine and pure oxycodone,” he says. “This is a product that is very easy to misuse, very easy to crush and snort or crush and inject. So it’s significantly more dangerous than the products that it would be competing with.” Kolodny cites Vicodin and Percocet as competing drugs that contain multiple other ingredients (in addition to a narcotic) that make them more difficult to abuse in those ways.

Patients in severe pain already have plenty of options, he says, and a marketing push to prescribe Moxduo could spell trouble.

“If they get this product put on the market and are able to have a sales force going in and out of doctors’ offices encouraging prescribing with the marketing claim that this is somehow a safer product … I believe that’s likely to exacerbate an already severe public health crisis,” Kolodny tells Shots.

For his part, Rudnic argues that the manufacturer already has good evidence that Moxduo is a safer painkiller with fewer side effects. And he disputes the claims that Moxduo is easier to abuse.

“I understand abuse and I understand the anguish that some of these people have that have lost a loved one to a drug overdose,” says Rudnic. “I lost a brother to a drug overdose in 2002 and it was really tough.”

Rudnic promises his company will set up a system to quickly spot any signs that Moxduo is being misused. QRxPharma is also developing a version of the drug, Rudnic says, that would make it harder to abuse.

The Food and Drug Administration Thursday announced that it wants the federal government to impose tough new restrictions on some of the most widely used prescription painkillers.

The FDA said it planned to recommend that Vicodin and other prescription painkillers containing the powerful opioid hydrocodone be reclassified from a “Schedule III” drug to a “Schedule II” drug, which would impose new restrictions on how they are prescribed and used.

OxyContin, another opioid painkiller, is already a Schedule II drug, defined by the Drug Enforcement Administration as “potentially leading to severe psychological or physical dependence”.

In a statement posted on its website, the agency said it was taking the step after becoming “increasingly concerned about the abuse and misuse of opioid products, which have sadly reached epidemic proportions in certain parts of the United States.”

The DEA has been asking the agency to recommend reclassifying the drugs for years, citing soaring numbers of Americans becoming addicted to the drugs and dying from overdoses.

Pain specialists and their patients, however, have been fighting the move, saying that any new restrictions would make it too difficult for those suffering from chronic, debilitating pain to get the drugs they need to survive.

The agency acknowledged the emotional debate, saying it “has been challenged with determining how to balance the need to ensure continued access to those patients who rely on continuous pain relief while addressing the ongoing concerns about abuse and misuse.”

Among other things, reclassifying the drugs would reduce the number of refills patients could get before having to go back to see their doctor. Doctors would not be able to simply call prescriptions into pharmacies.

The FDA said it would submit its recommendation to the Health and Human Services Department by early December, and anticipated that the National Institute on Drug Abuse would concur with the recommendation. That will begin a process that would lead to a final decision by the DEA.

More than 136 million prescriptions for these products are dispensed every year, making them the most widely used prescription drugs in the country. Vicodin is probably the best-known hydrocodone-containing product, but there are many others, sold under brand names such as Lortab and Norco.

While powerful painkillers, opioids are highly addictive and are abused by millions. The number of Americans overdosing from these drugs has been increasing rapidly in recent years, and more than 15,000 now die every year, according to the Centers for Disease Control and Prevention.

But about 100 million Americans suffer from chronic pain, and many of them and their doctors fear the change would make it difficult, if not impossible, for these patients to get drugs they need.

Advocates for pain patients immediately reacted with concern to the announcement.

“The concern we have is that it may unintentionally make access for people with pain even more of a challenge than it is now,” wrote Bob Twillman of the American Academy of Pain Management in an email to Shots. “This could necessitate millions more office visits, with attendant costs approaching a billion dollars a year. The access issues will need to be addressed or we will have a lot more people with a lot more uncontrolled pain.”

The numbers are staggering. One hundred and sixteen million Americans experience pain that can last from weeks to years. Costs of treatment and lost wages total between $560 and $635 billion each year. Yet treatment does not always relieve a patient’s suffering.

In a Perspective published today in the New England Journal of Medicine, researchers outline how significant the problem of pain is in the U.S. and suggest approaches for more effective therapy. The piece recaps last year’s Institute of Medicine Report, Relieving Pain in America.

The writers say that undertreated acute and chronic pain is a “significant overlooked problem.” Dr. Phil Pizzo, Dean of Stanford’s Medical School, is co-author of today’s Perspective and led the IOM committee that reviewed the issue last year. In an interview, he described that both patients and doctors have differing approaches to pain and how to manage it. Some patients feel they need to tough it out. Others need someone to listen and work with them. Doctors may be either caring or judgmental about a patient’s pain.

Pizzo argues for a “cultural transformation, the need for us to enter in a caring dialogue with an open mind and receptivity and willingness to listen to the individual, spend time understanding and engaging in everything from self-help to directed help.”

A key component of the cultural transformation is education, he says. It’s startling, but medical schools don’t actually teach their students much about treating pain. Today’s Perspective reports that half of all primary care doctors feel only “somewhat prepared” to help their patients with pain and about one-fourth of doctors feel “somewhat” or “very unprepared.”

But the solution, Pizzo says, is not more specialists. Currently, there are about 4,000 pain specialists and they are mostly located in metropolitan areas. “We’ll never have enough pain specialists to really handle the magnitude of the problem across the United Sates and therefore we really need to work with state and regional communities, with schools and hospitals, to better educate the community of physicians on the front lines of care.”

Christine Miaskowski is an Associate Dean at the UCSF School of Nursing who specializes in research in unrelieved pain. She was not involved in today’s report. “The field has evolved from thinking of pain as a symptom,” she said, “to thinking of pain, particularly chronic pain, that needs to be managed as a medical condition. Just like we manage heart disease and we manage diabetes, we have to manage chronic pain.”

She said the report does an “impressive” job in combining calls for both clinician education and public education. Barriers persist in the patient’s mind to seeking adequate treatment for pain. Miaskowski described elderly patients who avoid treatment because they think pain is a normal part of aging or because they fear it will cost too much money to do a full work up to determine the cause of the pain.

When writing the original report last year, the Institute of Medicine instructed the panel of researchers not to delve deeply into the question of opioid pain relievers and the climbing rates of abuse and deaths by overdose. Both Pizzo and Miaskowski argued for the appropriate management of these drugs, so that patients with either acute or chronic pain do not suffer.